Provider Demographics
NPI:1710037791
Name:GORIS, JACK EVERETT (DDS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:EVERETT
Last Name:GORIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 CHASE RD
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1200
Mailing Address - Country:US
Mailing Address - Phone:574-753-4542
Mailing Address - Fax:574-722-5059
Practice Address - Street 1:1821 CHASE RD
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1200
Practice Address - Country:US
Practice Address - Phone:574-753-4542
Practice Address - Fax:574-722-5059
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120083891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice